Procedures

Scar Revision (Scar Repair)

Whether caused by injury, surgery, or burn, scars can be disfiguring. Scars stand out against the rest of the skin because scar tissue is made of collagen cells rather than ordinary skin cells. As a result, scars are usually a different color, and do not have sweat glands or hair follicles. The severity of a scar depends on many factors, including the size and depth of the wound, the blood supply to the area, and the thickness and color of the skin. Some people – especially those with deeper skin tones – have a tendency to produce prominent, raised scars called keloids.

The success of scar revision often depends on the type of scar. Some of the different types of scars include:

Atrophic scars, which are thin or flat.

Hypertrophic scars, which are thick, red, raised and occur within the edges of the wound.

Keloid scars, which look like hypertrophic scars, but are firm and extend beyond the edges of the wound. Keloids can be swollen and often itch or hurt.

Contracture scars, which occur when large areas of skin are lost. The edges of the remaining skin pull tightly together, often restricting adjacent tendons or muscles.

There are several methods used to reduce the prominence of scars and improve the skin's texture and flexibility: Steroid injections or applications, topical silicone applications, dermabrasion, vascular laser and laser skin resurfacing, tissue expansion, z-plasty and skin grafts are all methods used to revise scars. On rare occasions even radiation may be used for just a few days in order to reduce the appearance of scarring.

If you're considering scar repair, the following information will provide you with a good introduction to the procedure. For more detailed information about how this procedure may help you, we recommend that you consult a facial surgeon who is board certified or has completed a residency program that includes instruction in this procedure.

*Depending on the procedure used and the size of the scar to be repaired, the cost for scar revision surgery could be as little as $500 or as much as $3,000.

The goal of scar revision surgery is to improve the appearance of the scar by disguising it, relocating it, or minimizing its prominence. There is no way to remove scars completely.

Because scars are highly individualistic, maximum improvement may require more than one procedure, and more than one technique may be used.

What are some of the most common benefits of scar revision surgery?

Scars can negatively affect self-esteem or remind patients of traumatic accidents. They may be a focal point of unkind attention as well. They can itch or hurt (in the case of many keloid scars) or even restrict activity. While scar revision can't make a scar vanish completely, scar revision procedures can diminish the appearance of scars, and help restore a damaged self-image. Sometimes the procedure can even improve the function of the site treated by easing the stiffness of the skin.

What will happen at the initial consultation?

During the consultation, you and your surgeon will discuss the changes that you would like to make. She/he will explain the different options available to you, the procedure itself, and its risks and limitations. She/he will also explain the kind of anesthesia required, surgical facility, and costs.

Your surgeon will begin with a complete medical history. Patients with Vitiligo, pigmentation disorders, dark tans or deep pigmentation may require an initial skin test for evaluation prior to treatment.

All scars initially appear large, red and unattractive, but most become less noticeable –even invisible -- with time. For these reasons, many surgeons recommend waiting as long as one year after an injury or surgery before considering a scar revision procedure.

Take this opportunity to ask all the questions you have about the surgery, and ask to see photos of the doctor's recent patients, before and after surgery. Also ask for, and follow up on, patient references. Learning everything you can about your options, risks and benefits is the key to making an informed decision. See Questions to ask your doctor below.

How is scar revision performed?

Your doctor will be the best judge of which procedure is best for you. Here are some possible options:

Collagen Injections -Collagen Injections are used to raise, or fill in, sunken scars. Collagen is a natural animal protein, usually produced from purified cow skin. Before using collagen, you should take an allergy test to ensure that you are not allergic to the substance. The results of collagen injections are immediate but not permanent. The scars will eventually have to be re-filled as the body slowly absorbs the collagen.

Dermabrasion -Dermabrasion smoothes out surface irregularities such as deep lines or scars by removing the topmost layers of the skin. The afflicted area will be sprayed with a numbing chemical spray and then carefully "sanded" with a rotating wire brush or a diamond wheel until the desired amount of skin is removed.

Vascular Laser - Vascular laser works by shrinking the blood vessels that feed the scar. This treatment is done without anesthetic. During the process, the sensation is much like that of a rubber band snapping on the skin.

Laser Skin Resurfacing - There are two types of lasers used for reducing the uneven surface of scars: the CO2 Laser and the Erbium:Yag Laser. The CO2 laser is typically used for deeper scars, while the Erbium is used for superficial scars and deeper skin tones. Both lasers remove the topmost layers of skin, allowing new, smooth skin to form. There are some color lasers that can effectively treat the abnormal red pigmentation of hypertrophic and keloid scars as well.

Punch Grafting - Deeper scars can be filled in with skin grafted from other places on the body. A tiny instrument is used to punch a hole in the skin, removing the scar. Then a piece of normal skin, usually taken from the back of the earlobe, is put in the scar's place. The "plugs" are taped in place until they heal. The grafts do form scars of their own but they are less visible then the pitted scars they replace. This procedure is often done in conjunction with dermabrasion or laser skin resurfacing.

Silicone Gel Sheets - Silicone gel sheets can help flatten hypertrophic and keloid scars. These clear sheets are placed on the scar and wrapped firmly with tape.

Skin Grafts - In this procedure, doctors take skin from a healthy part of the body and transplant it to the injured area. Grafts aren't always cosmetically pleasing because the grafted skin may not match the surrounding skin's color or texture. The area where the graft came from will also scar -- but skin grafts can greatly restore function to a severely scarred area.

Steroid Applications and Injections - Steroids can help flatten and reduce the redness of hypertrophic and keloid scars. Steroids are applied or injected into the scar to break down the skin's collagen. This is especially effective on hypertrophic and keloid scars, both of which continue to form collagen after the wound has healed. These injections can also help reduce the itching and/or pain associated with these scars.

Tissue Expansion - In this procedure, a small balloon is inserted under a patch of healthy skin near a scar. The balloon is filled with a saline solution to stretch the skin. When the skin has been adequately stretched, which can take several weeks or months, the balloon is removed. The scar is then surgically removed, and the balloon-stretched skin is pulled over the previously scarred area and carefully closed.

Z-Plasty and Related Tissue-Rearrangement Techniques - Z-Plasty is a technique used on hypertrophic and keloid scars that do not respond to steroid treatments. The scar is surgically removed by cutting the skin around the scar in small triangular flaps. These flaps usually follow a Z-shape (hence the name), but the technique your doctor chooses will depend on the shape of the scar. The flaps are repositioned to follow natural lines and creases of the skin. The new scar is thinner and less noticeable. Z-plasty can also help relieve the pressure of contracture scars.

Where are the treatments performed?

Collagen injections are most often performed in the doctor's office, although they may also be done at an outpatient surgical center or at the hospital.

Dermabrasion is most often performed in the doctor's office, although it may also be done at an outpatient surgical center or at the hospital, depending on your preferences as well as your doctor's.

Vascular Laser treatments are performed in the doctor's office.

Laser skin resurfacing may be performed in a hospital, an outpatient surgical facility, or in the surgeon's office. Extensive laser resurfacing, or resurfacing performed in conjunction with another surgery, such as a facelift, is generally performed in an outpatient surgical facility or a hospital.

Skin grafts and flap surgeries are usually performed at a hospital.

Silicone gel is applied in your own home.

Steroid applications and injections are generally performed in the doctor's office.

Tissue expansion is often performed at an outpatient surgical center.

Z-Plasty and related techniques are often performed at an outpatient surgical center or in the hospital.

How much pain is there?

The amount of pain experienced varies from person to person, and depends on the method used. In general, more extensive procedures can give better correction of scars, but at the cost of greater operating time, more risk, longer swelling, slower recovery, and greater cost. You should discuss your goals, budget, and pain tolerance with your surgeon in order to help him/her determine the procedure, or combination of procedures, that will produce the best results for you.

Dermabrasion Although there is some bleeding during this procedure, there is not a much pain during the procedure itself, which is usually performed under local anesthesia that is injected or sprayed on to skin.

Vascular laser treatments may be slightly uncomfortable. As mentioned earlier, the sensation associated with the treatment is that of a rubber band snapping on the skin. A cold compress, such as frozen Aloe Vera gel, may be applied during the procedure.

Laser skin resurfacing – Most likely, you'll be awake during the procedure, and feel minimal discomfort. Most doctors use a local anesthesia or a local anesthesia with a sedative. This is similar to the anesthesia used by dentists.

Silicone gel sheets involve little or no discomfort.

Skin grafts, punch grafts and flap surgeries are performed under general anesthesia.

Steroid applications and injections and collagen injections – You will feel the pin prick of the needle and possibly pressure when the fluid enters the skin.

Tissue Expansion may be slightly uncomfortable. The surgery is often done under local anesthesia.

What can I expect after surgery?

Collagen Injections The result is immediate. Pitted scars look smooth and even. However, these results are not permanent. Periodic treatments are necessary to maintain results.

Dermabrasion After the procedure, the treated area may be covered with an ointment, a wet or waxy covering, and/or a dry covering. The skin may feel as though it is severely sunburned. Moving facial muscles and eating may be uncomfortable. Oral pain medication may be taken to ease the discomfort. In some cases, antibiotics may be taken in order to prevent possible infections. The skin is usually swollen for around 24 to 48 hours after the procedure. During this time, a scab begins to form over the treated area.

Vascular Laser The treated area may show purple discoloration, which should fade in five to 10 days. Generally after this period the scar should be less red and raised.

Laser Skin Resurfacing You may experience some swelling and discomfort. Cold packs are usually recommended to reduce the swelling.

If a bandage was applied after the surgery, it will be removed after approximately one week, and an ointment will then be applied. Some surgeons use a moisture retaining tape to bandage the treated area. Because this bandage must remain dry, you will not be able to shower until the bandages are removed.

If the treated area is not bandaged, you will need to wash the area several times every day. After each washing, you will need to apply an ointment, such as petroleum jelly, to the treated area. You will need to use caution in caring for the treated area. Scabs may form and last for about 10 days. If you are experiencing discomfort, an over-the-counter oral pain medication can be taken.

Punch Grafting The new skin is taped into place for about seven days to permit healing.

Skin Grafts and Flap Surgeries You can expect to feel some discomfort after facial scar revision surgery. Some swelling, bruising, and redness are generally unavoidable. Any sutures will be removed within days after the surgery but your skin needs more time to heal. In general, surgeons suggest limiting activities -- especially any activity that places undue stress on the area of the incision.

Silicone Gel Sheets After two to 12 months, scars should look flatter and smoother. The procedure may have to be repeated after several years since keloid scars have the tendency to return.

Steroid Applications and Injections You may experience mild soreness, as with any injection. The scar should reduce in redness and thickness. The procedure may have to be repeated after several years since keloid scars have the tendency to return.

Tissue Expansion Expect some fairly mild swelling and possible bruising. Stitches are normally removed within a week of the procedure.

Z-plasty and Related Techniques The treated area will be closed with fine stitches, which will be removed within a week of the procedure. As with most incisions, the area may swell or bruise slightly.

What is the recovery period like?

Dermabrasion Dermabrasion can take from seven to 14 days to heal. The healing process depends on the individual's healing response; for example, smokers are typically slow healers. The new skin will have a red tone, which normally fades in about two months. In rare cases, the redness can last for four to six months. Be sure to ask your doctor about restrictions, such as swimming in chlorinated water, which should be avoided for at least a month after the procedure. Avoid cosmetics until the skin heals. The new skin is also highly sensitive to sunlight: sunblock is a must.

After one dermabrasion treatment, most patients' scars are reduced about 50 percent in depth. Patients are normally advised to wait one year before having a second treatment. Dermabrasion can be combined with other treatments such as punch-grafting to correct deeper scars.

Vascular Laser Purple discoloration and swelling should subside within five to 10 days, leaving a flatter, more neutral colored scar.

Laser Resurfacing Recovery times depend on the depth of the resurfacing and the individual's capacity to heal. Redness may persist for several weeks, or longer. The redness will gradually lighten to pink, and then a lighter, more natural color.

After laser resurfacing, daily sunscreen is recommended to protect the sensitive new skin that is exposed. Ask your doctor to recommend a sun block with both UVA and UVB protection, and apply it daily. If resurfacing was performed around your eyes, wear sunglasses.

Skin Graft, Punch Graft, and Flap Surgeries Skin graft or flap surgery incisions can take several weeks or months to heal. Sometimes support garments and bandages must be worn for up to a year.

Tissue Expansion The area may be sensitive. Patients should avoid placing undue pressure on the treated area for several weeks.

Z-plasty Small stitches will need to be removed in a few days after the procedure.

What is the long-term outcome like for most people?

Collagen Injections The results are not permanent. Periodic treatments are necessary to maintain results.

Dermabrasion No procedure can completely eliminate scars. However, dermabrasion can effectively minimize their appearance. This procedure works particularly well after scar tissue has been removed and sewn closed, leaving a finer scar.

Vascular laser This treatment reduces blood flow to the scar, leaving it more neutral colored, flatter, and less noticeable.

Laser Resurfacing This procedure greatly reduces the appearance of scars. It can also normalize red or brown scars, making them less noticeable. Some scars, such as keloid scars, may require more than one treatment over several months or years.

Punch Grafting Punch grafting produces new scars but the new scar will be smoother and less apparent than the depressed scar was.

Skin Grafts and Flap Surgeries Once new blood vessels fill in, the new skin is satisfactory. However, the graft or flap may not exactly match surrounding skin. The pigment and texture may be slightly different.

Silicone Gel After two to 12 months scars should look flatter and smoother. The procedure may have to be repeated after several years since keloid scars have the tendency to return.

Steroid Applications and Injections The scar should reduce in redness and thickness. The procedure may have to be repeated after several years since keloid scars have the tendency to return.

The above is only a partial list of the criteria that your surgeon will consider in determining whether or not this procedure is appropriate for you. Be sure to ask your surgeon if he / she considers you an ideal candidate for this surgery.

Risks and Limitations

Complications during any surgery are possible but uncommon. The following are risks associated with any surgery:

Swelling

Bleeding

Infection

Scarring. All incisions leave a scar. Most scars heal well but in rare cases the scar remains thick and heavy.

Numbness or change in feeling

Fluid collection

Drug or anesthetic reaction

All scar removal or revision procedures run the risk of leaving a worse scar than the original scar. The risks specific to each procedure are as follows:

Collagen Injections Patients with a personal history of rheumatic diseases, collagen diseases or "autoimmune" diseases, cannot safely use injectable collagen. Patients must be tested to ensure that they are not allergic to the collagen.

Dermabrasion The most common risk is a permanent change in skin pigment. Darker pigment can usually be treated with skin lightening creams. Treatments resulting in lighter pigment patches are more common after deeper treatments and can sometimes be minimized by a chemical peel. Infection and scarring are also possibilities but are rare occurrences.

Vascular Laser There may be a small amount of blistering over the treated areas, which should heal within a few days. There is a slight risk of depigmentation (skin lightening) with this procedure. You will likely avoid this if your doctor tests a small section of your skin with different strengths of laser before the actual procedure.

Laser Skin Resurfacing Semi-permanent or permanent skin lightening may occur in the treated areas. Or, the skin may become hyperpigmented (darker) immediately following the surgery.

Heat from the laser may cause burns or injuries. To reduce the risks involved in this procedure, carefully follow all of your surgeon's instructions, both before and after surgery.

Skin Grafts, Punch Grafts and Flap Surgeries The biggest risk is that there will be complications reconnecting blood vessels. If the blood flow is hindered, the graft or flap can die and need to be removed.

The information on this web site is only intended as an introduction to this procedure and should not be used to determine whether you will have the procedure performed nor as a guarantee of the result. The best method of determining your options is to consult qualified surgeons who are able to answer specific questions related to your situation.

*Disclaimer: Costs source: According to the American Society for Aesthetic Plastic Surgery (ASAPS), nationally in 2010. Most surgeons offer convenient payments plans for this procedure. Cost does not include anesthesia, operating room facility, hospital stay, and other related expenses. Costs may also vary depending on location.

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